Provider Demographics
NPI:1801277363
Name:O'BANNER, JEFFREY (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:O'BANNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 S 3RD ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1952
Mailing Address - Country:US
Mailing Address - Phone:618-333-5480
Mailing Address - Fax:618-222-4790
Practice Address - Street 1:1995 HIGHWAY 51 S
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:TN
Practice Address - Zip Code:38019-3635
Practice Address - Country:US
Practice Address - Phone:901-476-2621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-10
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125067541207Q00000X
TN57210207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine